**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, facility policy and procedure, and interviews with staff, Physician #397 and Psychiatrist #398, the facility failed to ensure one resident (Resident #152) who was diagnosed with mental disorder and post-traumatic stress disorder received appropriate care, treatment and interventions to meet the resident's individual needs. This resulted in Immediate Jeopardy that was actual harm when Resident #152, who was known to inflict personal injury, opened a previously self-inflicted wound with an electrical cord, made multiple self-harming body cuts, threatened to harm others and had suicidal ideation without appropriate action by the facility. On 11/21/19 at 5:30 P.M. the Administrator, Director of Nursing (DON), and Quality Assurance Nurse #396 were notified the Immediate Jeopardy began on 11/03/19 at 6:24 P.M. when the facility was notified Resident #152 was found in her room bleeding from a previous self-cutting wrist wound that she had re- opened with an electrical cord. Resident #152 voiced multiple desires to commit suicide and harm self or others and had multiple incidents of self-cutting and aggressive behaviors and was not provided appropriate supervision, psychological services or interventions to guard against and treat the behavior. The Immediate Jeopardy was removed on 11/25/19 when the facility implemented the following corrective action: • On 11/21/19 Resident #152 was assessed by Licensed Practical Nurse (LPN) #294 at 2:30 P.M.; one on one was immediately initiated with escalation of the resident's behavior. The physician was notified of the behaviors at 2:30 P.M. and Resident #152 was sent to the emergency room for a behavioral assessment at 3:29 P.M. • On 11/21/19, a pink slip (emergent discharge) was obtained at 6:07 P.M. Resident #152 was transferred to a behavioral health facility at 10:45 P.M. upon return from the emergency room. • On 11/21/19, all residents with diagnoses of suicidal ideations and self-harm were identified, care plans were reviewed, and interventions were updated by the Minimum Data Set 3.0 (MDS) coordinator/designee. • On 11/21/19, a list of residents with a history of suicidal ideations and self-harm was placed at all nurse's stations. The lists will be reviewed and updated with all new admissions or changes of condition. Placement of list will be monitored daily by DON/or their designee. • On 11/21/19, all residents with indications or signs and symptoms of behavior escalation or who exhibit spontaneous self-harm or suicidal ideations will be immediately placed on some form of one on one monitoring including distant one on one due to various anxiety disorders to prevent further escalation or behavior. • On 11/21/19 by 9:30 P.M., all staff were educated by phone or in person on suicidal ideations and self-harm guidance by DON/or their designee. • The Executive Director will conduct an audit of all referrals with suicidal ideations or self-harm behaviors. Results of the audit will be reviewed in monthly during the quality assessment and assurance meetings for trends and further guidance beginning 11/21/19. • Beginning 11/21/19 the DON/designee will conduct staff questionnaires on what to do if residents exhibit suicidal ideations and self-harm. Questionnaires will be completed daily for two weeks, then five times a week for two weeks, then three times a week for two weeks. Results of the questionnaire will be reviewed in quality assessment and assurance meetings. • On 11/25/19, by 11:00 A.M. all staff were educated Licensed Practical Nurse (LPN) #357, Human Resources #360 and Staff Development Coordinator #372 on the procedure when a resident exhibits self-harming behavior. • On 11/25/19, observations from 3:50 to 4:02 P.M. confirmed the list of residents with a history of suicidal ideations and self-harm was posted at the nurse stations. • Interviews on 11/25/19 at 11:55 A.M. with LPN #288 and at 12:03 P.M. with State Tested Nurse Aide (STNA) #237 verified education was completed. Although the Immediate Jeopardy was removed on 11/25/19, the facility remained out of compliance at Severity Level 2 (No actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing behavior interventions/suicide precautions for Resident #152 and other residents at risk, implementing new policies and procedures for recognizing suicidal or self-harm behaviors, completing audits on all referrals with suicidal ideations and completing staff questionnaires on recognizing resident with self-harming or suicidal ideations. Findings include: Resident #152 was initially admitted on [DATE] and readmitted on [DATE] following a hospital admission for self-harm and suicidal ideation. Diagnoses included post-traumatic stress disorder, major depressive disorder, suicidal ideations, laceration of left wrist and borderline personality disorder. Resident #152's five day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed cognitive skills for daily decision making was moderately impaired; little interest or pleasure in doing things; felt or appeared down, depressed, or hopeless; felt tired or had little energy; had a poor appetite; felt bad about self, was a failure, or has let self or family down. Resident #152 was short tempered and easily annoyed, and stated that life was not worth living, had wishes for death or attempted to harm self. Review of Resident #152's general progress note dated 11/03/19 at 6:24 P.M., authored by LPN #294 revealed the receptionist stated a friend of Resident #152 called to say Resident #152 had cut herself again. LPN #294 and two other nurses entered the room and observed the resident lying on her side in bed using the cell phone. Resident #152 was asked to let them see her arm and she refused. After 15 to 20 minutes, she showed the nurses her arm, and the bandage was not on a previous self-inflicted wound. The area had been re-opened and bleeding was observed. The nurses cleansed the resident's arm and applied a bandage. Resident #152 stated she used an electrical cord to open the wound. The progress note indicated staff remained in the room offering emotional support and would continue to monitor. Resident #152's medical record contained no evidence of monitoring measures related to Resident #152's self-harming behavior. Review of Resident #152's general progress note dated 11/05/19 at 1:38 A.M. revealed the resident remained in her room, refusing meals, refusing medications, and assistance with activities of daily living. Resident #152 was verbally aggressive with staff and accused staff of wrong doings. All attempts to get the resident to be compliant failed and the staff reassured Resident #152 of her safety and their willingness to assist her. Per the progress note Resident #152 was in her room at this time and the staff would continue to monitor. Review of Resident #152's general progress note dated 11/05/19 at 6:28 A.M., authored by Registered Nurse (RN) #309 revealed the facility received a call from a local crisis hotline indicating Resident #152 had slit her wrist. RN #309 went to assess the resident and noted dried blood on her right inner wrist. Resident #152 refused to show the nurse and denied calling the hotline but was observed with the phone in her hand. The progress note indicated the wound appeared old, measured 1 centimeter (cm) by 0.5 cm, and was wrapped with Kerlix. The nurse manager and physician were notified. Resident #152's general progress note dated 11/05/19 at 7:15 A.M., authored by RN #308, revealed the resident was calling the suicide hotline all night long, and peeled off an old scar on the ventral right wrist, measuring 4.0 cm long, 1.0 cm wide, and 0.1 cm deep. The wound had some fluid drainage. The progress note indicated staff wound continue to monitor. The medical record contained no evidence of monitoring the resident to ensure safety or providing additional psychosocial support related to self-harming behavior. Resident #152's general progress note dated 11/05/19 at 12:14 P.M., authored by LPN #285 revealed staff went in the resident's room to assist her when she turned her call light on. Resident #152 started yelling that she wanted to leave and to leave her alone. The resident threw herself on the floor, started banging her head on the floor, punching the dresser, kicked the wheelchair over and attempted to pull the television down on herself. Resident #152 stated she was cutting herself because she wants to kill herself. Resident #152 had a piece of plastic that she was attempting to cut herself with. LPN #285 and the DON went in the room to speak to the resident, calm her down, and redirect her, and were unable to do so at the time. Emergency Medical Services (EMS) was called, and the resident was sent to the hospital. Resident #152's general progress note dated 11/05/19 at 10:50 P.M. revealed the resident returned to the facility with two new orders, an antibiotic for cellulitis and potassium for low potassium. The resident seemed calm and pleasant. The note indicated the facility would continue to monitor. Resident #152's medical record contained no evidence of additional safety measures or psychosocial services related to suicidal ideations and self-harming behavior. Review of Resident #152's general progress note dated 11/08/19 at 10:39 A.M. by LPN #293 revealed the resident came towards the nurses' station and began to yell at staff. The nurses attempted to calm the resident down and while wheeling herself back to her room she yelled at another resident. Resident #152 then attempted to hit the other resident and staff were able to move the resident out of the way before physical contact was made. LPN #293 then went to calm Resident #152 down and the resident began to punch a window. The nurse pulled back the resident's wheelchair form the window and the resident attempted to hit the nurse. The nurse explained to the resident that she could hurt herself, and it was not acceptable behavior. The DON and Administrator were able to calm Resident #152 down and she was provided with education on appropriate behavior and ways to deal with emotions in a healthy manner. Review of Resident #152's general progress note dated 11/08/19 revealed the resident was seen by the physician with no new orders. Review of Resident #152's general progress note dated 11/10/19 at 5:33 P.M., authored by LPN #285 revealed STNA #221 went into the resident's room to check on her and notified the nurse that she saw blood on the resident's sheets. LPN #285 went in to see the resident. The resident hid her arms on the side of the bed and started screaming for the nurse to get out. The supervisor was called to the floor, and upon assessment the resident had scraped off the scabs on her wrists from her previous wounds. The wrists were cleaned and wrapped by the nurses. Fifteen minutes later, staff went to check on the resident and she had taken the bandages off and she had the clip from the call light in her hand. The clip was taken, and she was brought to the television area where she could be observed by staff on a one on one bases. Resident #152's medical record contained no evidence of how long she remained one on one supervision or that she was assessed to determine the risk of harming herself further. Interview on 11/21/19 at 12:38 P.M. with the DON confirmed there was no evidence of the duration of her one on one observation or additional safety measures put into place on 11/10/19. The DON revealed the facility started seeking alternative placements for the resident on 11/08/19. Review of Resident #152's general progress note dated 11/14/19 at 10:13 A.M., authored by LPN #285 revealed the resident was in the dining room for breakfast in the morning. Staff walked into the dining room and the resident started screaming at staff to get the (expletive) away from her and stop talking about her and calling her names. Resident #152 started yelling that she was going to kill a staff member. Other residents told Resident #152 to be quiet, and she yelled at them to shut the (expletive) up or she would kill them too. Resident #57 and Resident #7 went to the nurse stating Resident #152 should not be around them and they did not feel safe. At this time, therapy went to get Resident #152 and took several minutes to calm the resident down to go to therapy. When therapy brought Resident #152 back, the therapist reported that the resident kept saying she was going to hurt someone or herself. Resident #152 stated she wanted to kill someone, and the nurse attempted to talk to the resident and the resident would not listen. Resident #152 requested to speak to the administrator and said that she wanted to leave. Resident #152's general progress note dated 11/14/19 at 5:33 P.M., authored by RN #302 revealed the resident was totally out of control. Resident #152 threw a tray in the dining room at another resident, was yelling foul language at residents, and showing her fist to other residents. Resident #152 threw a chair on the floor, punched a computer, and was not redirectable. A call was placed to the psychiatrist regarding transfer out of the facility to another facility, but the facility they wanted to transfer her to declined the resident's admission. Resident #152's general progress note dated 11/14/19 at 11:00 P.M., authored by LPN #286, revealed the resident believed she was leaving the facility on this day, and stated if she was not allowed to leave, she would find a way to commit suicide. Resident #152 became more agitated and was screaming. Resident #152 was sent to the hospital emergency department at 10:23 P.M. Resident #152's general progress note dated 11/15/19 at 11:18 A.M. revealed she returned to the facility and the facility would continue to monitor her. The medical record contained no evidence the resident was monitored more closely or was provided psychosocial services related to self-harming behavior. Review of Resident #152's general progress note dated 11/17/19 at 1:12 A.M. revealed the nurse was called to the resident's room by STNA #240 at 1:00 A.M. STNA #240 stated it appeared the resident was attempting to harm herself. The nurse entered the room and the resident was sitting in a wheelchair hiding her left arm behind her. Droplets of blood were noted on floor beneath the wheelchair, and the skin to her left wrist was observed to be open. Resident #152 refused to identify the object used to cause the injury and no objects were visible for staff to identify. Staff remained one on one with the resident and she was sent to the emergency room for evaluation. Resident #152's general progress note dated 11/17/19 at 10:57 A.M., authored by LPN #294 revealed the resident returned to the facility. Staff reported she did not want to return to the facility and would continue to cut herself. The medical record contained no evidence the resident was monitored more closely upon her return or was provided psychosocial services related to wanting to harm self. Resident #152's general progress note dated 11/17/19 at 6:31 P.M., authored by LPN #294 revealed the resident was lying in bed, refused meals, and stated she cut herself again, and asked the nurse not to tell anyone. The previous arm wound was reopened, and dried blood was observed around wound. The resident refused to have the wound cleaned and wrapped and stated, I'm not done yet. Resident #152 was re-educated regarding keeping the wound clean and wrapped. The progress note indicated the staff would continue to monitor. The medical record contained no evidence of what monitoring measures were in place or that the physician was notified. Review of Resident #152's general progress note dated 11/18/19 at 2:17 A.M., authored by RN #308 revealed at 1:00 A.M. the resident was assisted to her wheelchair and stated she would like to be discharged . When told she would not be discharged at this time, she stated she was going to kill herself. The progress note stated Non-emergency police were invited to help calm her down, which was ineffective. Resident #152 was sent to the hospital. Resident #152's general progress note dated 11/18/19 at 2:47 A.M., revealed the resident returned from the hospital with no new orders and they would continue to monitor her. The medical record contained no evidence of what monitoring measures were in place or additional psychosocial services provided. Interview on 11/21/19 at 11:23 A.M. with Resident #152 revealed she tried to kill herself and she pointed to a bandage on her right wrist. Resident #152 stated State Tested Nursing Assistant (STNA) #200 was evil when she was first admitted , by stating get you're (expletive) up and you can walk. Resident #152 revealed Licensed Practical Nurse (LPN) #281 agreed with STNA #200 so it got worse. Resident #152 revealed when STNA #200 worked the next time the STNA stated get you're (expletive) up and I do not give a (expletive) what you think or care who knows. Resident #152 revealed she started crying and she has post-traumatic stress disorder (PTSD) and depression. Resident #152 stated when STNA #200 left, that is when she tried to commit suicide because everyone has abused her in her past. Resident #152 revealed she asked the facility for counseling and they said no, and the staff say they do not have time. Resident #152 revealed she tried calling the crisis hotline to talk to someone at one point, so she would not try and hurt herself, and the hotline called the facility. In addition to the right wrist bandage, Resident #152 was observed with scars on her neck and left wrist from previous wounds. Interview on 11/21/19 at 12:38 P.M. with the DON revealed Resident #152 was accepted at a behavioral health facility on 11/20/19, but the resident declined to go, and started to come out of her room more around this time. Quality Assurance Nurse #396 revealed the staff on the floor were trained on how to respond to the resident's behavior. The DON indicated Resident #152 needed a behavior modification plan, but it was difficult if she did not agree. Quality Assurance Nurse #396 revealed when Resident #152 comes back to the facility from the hospital, her behaviors are subdued, and the facility continues to monitor her. Interviews on 11/21/19 between 12:28 P.M. and 5:15P.M. were completed with the DON and Quality Assurance Nurse #396. At 12:28 P.M. the interview revealed after Resident #152 harmed herself on 11/03/19 they took the electrical cords away, and she was checked on every two hours. Additional information from the interview, at 12:28 P.M. revealed after Resident #152 opened a previous wound on 11/05/19 at 6:28 A.M. The nurses tried to calm the resident down and divert her attention. The DON revealed they did not increase supervision for the resident because she did not like someone constantly with her; they were able to walk past her room and observe what she was doing. The DON indicated the resident did not disclose what she used to cut herself, but her room was searched without finding anything. The DON revealed the resident eventually disclosed using a plastic piece from the cap of a needle to cut herself. The DON revealed the resident was supposed to see the psychiatrist on 11/05/19, but because she was hospitalized , she was not seen. The DON stated the psychiatrist did not see Resident #152 until 11/11/19. The interview confirmed the unit manager and nurse practitioner were notified of Resident #152's self- harming behavior on 11/17/19 although it was not documented. Interview on 11/21/19 at 2:53 P.M. with the DON revealed Resident #152 was not offered counseling services, as counseling services were stopped on the resident's floor. Interview on 11/21/19 at 4:54 P.M. with Physician #397 revealed Resident #152 has been sent to the emergency room multiple times and they keep sending her back. Physician #397 revealed when a resident cuts themselves they are usually always sent out. Physician #397 revealed the hospital gives the facility the clear that they can come back, as the resident does not have any psychiatric issue that needed to be addressed. Interview on 11/21/19 at 5:15 P.M. with Psychiatrist #398 revealed the expectation when a resident exhibits self-harming behavior is to make medication adjustments if needed and observe the resident for safety. Review of the undated facility policy, titled Suicide Threats revealed staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse. The nurse supervisor/charge nurse shall immediately assess the situation and notify the charge nurse/supervisor and/or DON of such threats. A staff member shall remain within view of the resident until the nurse supervisor/charge nurse arrives to evaluate the resident. After assessing the resident in more detail, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update physician accordingly, until a physician has determined that a risk of suicide does not appear to be present. Staff should monitor the resident frequently as not to increase further agitation, if the resident allows sit with the resident and provide distraction, comfort, and ensure safety. Staff shall document details of the situation objectively in the resident's medical record.